The Institute of Forensic Sciences (ICF, in Spanish) and the Demographic Registry turned to technology and training to improve the protocol that records deaths related to Hurricane Fiona to minimize the mistakes made five years ago when Hurricane María hit Puerto Rico.

The deaths linked to Hurricane Fiona, which slammed Puerto Rico on September 19, will presumably be known faster than in the María-related emergency because of the use of the platform called the Vital Information Tracking Application (VITA), which allows digitally recording of the different data items of a death certificate into the Demographic Registry, said ICF Director María Conte, and Wanda Llovet, director of the Registry. 

Nearly half of the certificates are still being filled out manually. Llovet said that from June 1 to August 30, 52% of deaths have been reported through the electronic system and the rest manually.

This is largely because 39% of hospitals are still not using the new platform, waiting for their medical staff to be trained; those certificates are still being registered manually. Eighty percent of all deaths in Puerto Rico occur in hospitals or health centers where they are certified by doctors, and the ICF handles the rest.

There are 68 hospitals in Puerto Rico. According to the Department of Health’s Emergency Management Operational Plan. The 130 Diagnostic and Treatment Centers (CDT, in Spanish), are not included in this usage percentage of the platform because they will be integrated into a future stage.

Staff at the ICF and the Registry, as well as funeral agents, have already been trained. The tool is expected to eliminate discrepancies between ICF and Registry figures because both agencies use it, Conte noted.

Before VITA’s implementation, fully recording a death in the database was done manually and took an average of one to two months in non-emergency times and now takes eight to 10 days, the Department of Health (DS, in Spanish) estimated.

The process of completing a death certificate and recording a death — even electronically — includes several steps that depend on the type and place of death, whether the death is certified by a doctor or goes to the ICF for investigation. From one of these two places, the certificate — paper or electronic — passes to the funeral agent before the information is finally reviewed and validated by Registry staff, the last link in the official registration of a death in Puerto Rico’s mortality database.

However, Llovet said the Registry can already see the deaths and their causes immediately on this platform and its staff reviews the cases daily. Both officials added separately that they trust the diligence and accuracy with which the doctors fill out the death certificates, so the distinction can be made about which are hurricane-related deaths.

During Hurricane María, the death data collection system collapsed when the Demographic Registry’s offices were closed due to a lack of electricity, fuel for generators, and communications. When they were able to reopen the central office, they started logging the death certificates that were done on paper weekly and delivered to those offices, so the information was not available for many months. The information was finally provided to the Center for Investigative Journalism (CPI, in Spanish) after a court request for access to information in May 2018. Hurricane María hit Puerto Rico in September 2017.

Meanwhile, the ICF director said the new system should help take “immediate action and mitigate those situations that are causing those deaths” during natural disasters, unlike María when there was no information available because certifying deaths took a long time, as it was done manually.

“Now we’re much more on the lookout for what the situations are, the Registry is more aware of the report, the statistics are coming out faster and the doctors, in general, are more conscious,” Conte said.

The director of the Registry said that even when processed digitally, the steps followed are the same as those of the manual system, but recording the information electronically speeds up the process.

“The doctor is the one who certifies the cause of death. Subsequently, that certificate, which is document RD77, is sent to the funeral home that’s going to handle the funeral arrangements for them to complete the other part of the death certificate. Once the medical and demographic parts are completed, the funeral home moves on to submit the certificate to the Demographic Registry,” Llovet explained.

The director of the Registry added that “the time is reduced because I no longer need to have the staff enter the data after we receive the certificate. The information is entered directly from the hospital, the part that corresponds to the doctor. Later, it goes to the funeral home electronically. The funeral home fills out the part electronically as well, and when it gets to the Registry, that certificate is already fully electronic.”

On the other hand, Conte explained that, since an ICF pathologist must evaluate cremation cases, it is possible then to detect if a case is related to the hurricane, even if the death certificate does not say so.

Oversight system is created

Llovet said that a supervising committee comprising epidemiology staff from the ICF, and the Centers for Disease Control (CDC) was created, which meets several times a week to discuss the cases of deaths that have come in after Hurricane Fiona. She said the team’s epidemiologists check the news and get calls from hospitals about deaths that are suspected to be related to the hurricane.

However, she added that in cases of deaths not evaluated by the ICF, the certification that death is directly or indirectly attributed to Hurricane Fiona is established by a doctor. 

According to the DS data, as of September 28, there were 24 cases of deaths associated with Hurricane Fiona, of which 13 are under investigation and 11 are confirmed. Of the confirmed deaths, there is one direct death and 10 indirect ones.

Both officials recalled that after Hurricane María, and due to mistakes in attributing the causes of death to the hurricane, doctors were trained to properly fill out the death certificates, based on CDC guidelines on how to document the deaths and tie them to an atmospheric event. They noted that after the pandemic, they saw doctors properly documented COVID-19 deaths. So, they’re relying on that accuracy being replicated when filling out death certificates after Fiona.

Meanwhile, Conte said the ICF is available to address medical consultations about potential hurricane-related deaths. The pathologist said doctors certify causes of death based on clinical conditions they treat on a daily basis and that it was after the deaths occurred after Hurricane María, that they became aware that patient conditions can be worsened by a hostile environment or condition. However, she said that as part of their training, forensic pathologists get a lot of education on how to link a death to an atmospheric event.

The director of the ICF also said the agency maintains open communication channels with hospitals, so that they can consult via email the cases that must be referred to Forensic Sciences.

“I want to emphasize that those cases [related to the hurricane] don’t necessarily have to be sent to Forensic Sciences unless it’s a traumatic death. But if it wasn’t a traumatic death, if it was an indirect death, because the person used oxygen at home and the power went out and they had a known medical condition, then the doctor doesn’t have to send us those cases, they don’t necessarily have to reach the ICF as long as a doctor certifies it as a hurricane-related death,” said the doctor in pathology.

Conte said they have also re-educated their staff regarding the CDC’s guidelines to carry out this type of screening. In addition, they are using the forms that the CDC uses to interview relatives and witnesses of these suspicious deaths, so that they can recognize if, in fact, they are attributable to the atmospheric event.